New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter IV - Regulation And Quality Control
Subchapter D - Operation Of Facilities
Part 81 - Operation Of Schools For The Mentally Retarded
Section 81.8 - Records and statistics

(i) legal admission documents;

(ii) identifying information on the individual and his family;

(iii) source of referral, date of commencing service and name of staff member carrying overall responsibility for treatment and care;

(iv) initial, intercurrent and final diagnoses, including psychiatric or mental retardation diagnoses in official terminology;

(v) reports of all diagnostic examinations and evaluations, including findings and conclusions;

(vi) reports of all periodic medical, dental, eye and hearing examinations;

(vii) reports of all special studies performed, including X-rays, clinical laboratory tests, clinical psychological testing, electro-encephalograms, psychometric tests;

(viii) the individual written plan of care, treatment and training (section 81.6[a][2] of this Part) or the program narrative as discussed in section 27.3(f) of this Title for integrated residential communities as defined in section 27.2(g). Integrated residential communities pursuant to section 27.2(g) shall comply with section 27.3(f) and are exempt from the requirements of subparagraphs (a)(2)(ix), (x) and (xii) of this section;

(ix) progress notes written and signed by all staff members having significant participation in the program of treatment and care;

(x) summaries of case conferences and special consultations;

(xi) dated and signed prescriptions or orders for all medications with notation of termination dates;

(xii) a closing summary of the course of treatment and care; and

(xiii) documentation of any referrals to another agency.

(i) Admissions, discharges and other statistical information shall be reported to the department as required and on the forms prescribed therefor.

(ii) Statistical reporting shall be the responsibility of an appropriately qualified employee whose name and title shall be made known to the department.